Preconceptional care (PCC)(The Critical role of Primary Care Physician)(The Critical role of Primary Care Physician)

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

Introduction to Primary Care

a course of the Center of Post Graduate Studies in FM

Content of this session

1. Overview

2. Rational of PCC.

3. Objectives of PCC.

4. PCC implementation at PHC centers.

5. Physicians' role - delivering PCC.

6. Obstacles of PCC.

7. Premarital check-up.

8. Woman’s role.

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Birth Rate United State 13.82 births/1000 population

Saudi Arabia 28.55 births/1000 population country comparison to the world 52

Egypt 21.70 births/1000 population

United Arab Emirates 16.02 births/1000 population Japan 7.64 births/1000 population

Prematurity & Infant Mortality United State 7 deaths/1000 live births.

Saudi Arabia 11.7 deaths / 1000 live births

United Arab Emirates 12.70 deaths / 1000 live births Egypt 27.26 deaths / 1000 live births

Japan 2.4 deaths / 1000 live births

Central Intelligence Agency, The WORLD FACTBOOK

Factors Leading to Infant Mortality

Maternal health problems Smoking Age <20 or > 40 Late entry into prenatal care Education Marital status Inter-pregnancy interval

Potentially all related to

Maternal Health Prior to Maternal Health Prior to PregnancyPregnancy

(Preconception)(Preconception)

Key Factors

Health status overall

1. Nutrition

2. Exercise habits

3. Infection risk (immunization)

Specific health risks

1. Chronic medical conditions

2. Medication

3. Tobacco use

Preconception Care: A window of opportunity

• All women of child-bearing yrs : pre- screened for health & risk potentials Before attempting to be pregnant. • Optimum: 3- 6 ms before conceiving attempt This time frame allows: 1- Successful conception & pregnancy 2- any within control health risks.

PCC has been advocated as a measure to improve pregnancy outcome.

Its components parallel those of prenatal care : risk assessment, health promotion and medical & physiological interventions.

Physician’ s role : providing PCC.

Woman’s role : ….

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Rational of PCC

Screening tool for physicians to assess women’s health

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Objectives of PCC

In one sense, PCC can be compared to: Will Baby Clinic visitWill Baby Clinic visit

a baby is screened for Normal health, Normal Development to identify emerging unnoticed problems in an infant.

1. Existing or emerging illness or disease which may have gone undetected before.

2. Existing risks for the woman who may become pregnant.

3. Existing risks which may affect a fetus if the woman does become pregnant.

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Objectives of PCC

For a WomanFor a Woman: : PCC assess Normal health of a child-bearing woman, to identify: -

PCC can be provided most effectively as part of ongoing primary care.

Physicians can deliver PCC during visits for • Routine health maintenance, • During examinations for school or work, • At premarital or family planning visits, • After a negative pregnancy test or • During well-child care for another family member.

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PCC at PHC centers

• Comprehensive check-lists.

• Assessments – History & examination.

• Screening: Investigations.

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Components of PCC

Prescreening check-lists : 1. Reproductive & non- reproductive systems. Covers physical & psychological aspects.

2.Woman's lifestyle

3.Family history information. Begins with basic information then in-depth,

especially if there is previous disease/operation. Pre-screening assessments: a Questionnaire filled by

women generally before seeing the physician with a nurse.

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What is involved in PCC?

1. Medical conditions.

2. Genetic counseling.

3. Immunization.

4. Lifestyle changes.

5. STDs (STI)

6. Medications.

7. Occupational exposures.

8. Domestic violence.

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Assess & screen for:

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Medical conditions:1. DM:

• Screen for DM and pre-diabetes.• If already diabetic --- shift to insulin Rx.

Congenital anomalies: 2- 6x > offspring of DM. PCC care & good DM control their rate Recent meta analysis: lower rate among PCC recipients (2.1%)

vs non-recipients (6.5%).

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2. Hypertension.

3. UTI & Renal problems.

4. Obesity .

5. Cardiac / pulmonary problems.

6. Epilepsy .

7. Psychological disorders.

Medical conditions:

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Genetic counseling in PCC is ideal time:

Before a couple attempts to conceive especially if the history reveals :-

Advanced maternal age,

Previously affected pregnancy,

Consanguinity or FH of genetic disease.

Premarital couselling

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Examples Genetic counseling

1. Blood conditions caries/ disease:o Sickle cell anemia, thalasemia, G6PD

2. Cystic fibrosis.

3. Mental retardation condition: Screen women with a known FH of fragile X syndrome or

FH of unexplained mental retardation or for women who have learning disabilities or mental retardation.

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Immunization

PCC is ideal time: Screen for rubella immunity.

Immunization: RubellaHepatitis AHepatitis BTetanusChickenpox?

Check : EIP complete? women <18 yrs.EIP = Expanded Immunization Program)

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Lifestyle changesCaffeine: 1 cup coffee : ~ 120 mg caffeine. 1 cup tea : ~ 40 mg caffeine. 12- oz soft drinks (cola) : ~ 45 mg caffeine.

Caffeine metabolism during pregnancy especially with cigarette smoking.

Several studies: caffeine intake ± associated with fertility abortion birth wt.

5-6 mg/kg/day spread on day + no smoke + no alcohol : NO reproductive risk.

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Lifestyle changes

Tobacco :

Smoking women during pregnancy : subjects themselves & their infants to a no. of adverse health effects.

women contemplating pregnancy should quit smoking prior to conception.

Nicotine replacement could then be prescribed.

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Lifestyle changesTobacco :- Smoking cessation before / early pregnancy : associated with

improvement in maternal airway function & at infant birth wt vs among nonsmoking pregnant women.

Alcohol & illicit drugs Both a major health problem in USA. Both harm fetus. 1981- USA : women abstain drinking alcohol during pregnancy

& when plan pregnancy.

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Sexually Transmitted Infection (STI = STD) & medications

STI : PCC is a good opportunity to screen for genital infections such as Chlamydia, gonorrhea, syphilis and HIV.

Medications : therapeutic regimens for chronic illnesses are best modified, if possible, in PC period to include the drugs that have been used the longest & have been determined to pose the lowest risk.

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Medications

Antihypertensives: Diuretics & angiotensin-converting enzyme should be avoided

drug of choice: methyldopa- proven maternal & fetal safety.

Anticoagulants: Warfarin ContraIndidated Switch to heparin

Oral hypoglycemic: Switch to insulin before pregnancy.

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Occupational exposures

Worldwide: women entry to workforce. Most women are in reproductive age

Three most common occupational hazards reported to affect pregnancy are:

Radiation Exposure

Organic solvents

Lead

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Domestic violence

Is increasingly Is increasingly recognized as a major public health issue.It crosses all racial, religious & educational boundaries.

Physical abuse during pregnancy : significant Risk Factor low birth wt & maternal complications.

Physicians should assess the victims & refer to local community resources.

1) Pregnancies are still unplanned.

2) Women do not know, realize, or understand the benefits of visiting their physician before become pregnant.

3) The lack of health insurance.

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Obstacles of PPC

Premarital check up : Mandatory For limited inherited risks.

It could be provided to the married women at the center by:-

health education of the patient at Pre-Natal Care Well baby clinic , Chronic disease clinic ….etc

Let the patient be aware of its importance

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PCC in Saudi Arabia

A woman may need to adjust certain aspects of her health and well-being which are in her control.

These usually include aspects of lifestyle, drug and alcohol use, exercise, rest and stress reduction.

In addition, she may need to discontinue certain herbs or over-the-counter medications as recommended by the physician.

Many physicians will also recommend pre-natal vitamins before a woman actually conceives in order to boost her overall health.

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Woman’s role

تم بحمد تم بحمد Thankاللهاللهyou

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MCQMCQ

1 (Birth rate is

a) Annual number of births during one year/ 1000 population.

b) Crude birth rate.

c) Usually determine the rate of population growths.

d) All of the above.

2 (Infant mortality rate

a) Number of infant deaths in one year/1000 live birth in same year.

b) Include total death rate.

c) It indicate the level of health in a community.

d) All of the above.

3 (Factors leading to infant mortality include all EXCEPT

a) Maternal health problems.

b) Smoking.

c) Age >20 or < 40

d) Late entry into prenatal care.

4 (Drugs that need to be changed for safe motherhood are

all EXCEPT a) Diuretics

b) Warfarin

c) Insulin

d) Angiotensin-Converting Enzyme Inhibitors